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AP Ip ge P�essed When Submitted Properly Gomplemu. <br /> APPLICATION ///}}} <br /> M(COMPLETEI <br /> C6M lb�� (For Non-Translerable,Revocable,Suspendable) PUMP&WELL /// <br /> I ENVIRONMENTAL HEALTH PERMIT o{ <br /> iWATER QUALITYATE) Health District. <br /> 1 Application ishereby madeto the San Joaquin District regulations <br /> inftehework herein describe-q hDi9rict. anon is <br /> made in compliance with-San�f n JJoaquir�County Ordinance No.t�the rules and regulatioCn y/Tohe San Jo��n Lor`e� <br /> w5y�7/ <br /> Exact Site Address phone <br /> Owners Name 0 City y!.� <br /> Address �d License# /� 7 Business Phone— - 2e oma+ <br /> 11 <br /> Contractor's Nam Emergency Phone t <br /> r Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File th SJLHD? Yes <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN❑ RECON❑DITI P❑P INSTALLATION 13PUMP REPAIR'{ <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER .y ' _ <br /> REPLACEMENT❑ Sewer Lines Pit Privy �— <br /> t DISTANCE TO NEAREST: Septic Tank Y Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> TYPE OF WELL <br /> p INTENDED USE ❑ CABLE TOOL Dia.of Well Excavation <br /> ` <br /> 9 INDUSTRIAL pia.of Well Casing <br /> t ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑_GRAVEL PACK Depth Of Grout Seal <br /> 11 IRRIGATION Type of Grout <br /> ❑ CATHODIC PROTECTION 13 13 ROTARY Other Information <br /> y6 ❑ DISPOSAL 'nSurface Seal Installed BY. <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor❑ State Work Done <br /> H,IP AU — <br /> Type of Pump _ - <br /> r <br /> PUMP REPLACEMENT: l)U <br /> PUMP REPAIR: ® State Work Done �`f�ta RYv u Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter d y <br /> Describe Material and Procedure _ <br /> I hereby certily that I have prepared this application and that the work will be done in accordance with Sen Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Jgoaquin.Local Health District. <br /> of Home owner or licensed agentt'ie sl9naslouiro'c Jleh he f following; <br /> becomtify that in the e subject to perfo workman's compenc nsation rk for <br /> of California."; <br /> e pis issued, l shall not employ Y Pa . <br /> fi Contractor's hiring or sub-contracllingsignature <br /> certifies <br /> to workmenollloowinpg nScertifyLthatavvS a�California." <br /> mance of the work forwhich s <br /> permit is issued. I shall employ psubject <br /> I wi call for a Grout Inspecgo p to o ng all al Inspection. <br /> Tri Dale: <br /> 11 Signed X (priaw Plot PI n Reverse Side) \ <br /> FOR DEPARTMENT USE ONLY <br /> ( Uq Date <br /> ' PHASE 1 - - <br /> Application Accepted By�C <br /> k ITL&I <br /> Additional Comments: h 111 Final t svection : v <br /> Phase 11 Grout Inspection ! _ Date ZJ <br /> Date Inspection By <br /> I Inspection By <br /> ❑ January 1.a Ra eived By January 31 July 1 8 Received By July 31 <br /> I FH Is Doe: ❑ ANNUALLY O PER UNIT ❑ PER SITE [3 EACH REMIT <br /> BILLING REMITTANCE S AMOUNTOUE CHECKED <br /> { BASE EXPLANATION GATE DATE 'REMITTED AMOUNT <br /> r � <br /> FEE <br /> 6 - <br /> i PESS <br /> RORATION <br /> T <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> v i N to Mal{ed Dell ad <br /> Receival by Date Rec PIN , <br /> 7 APPLICANT—RETURN ALL COPIES TO: . ENVIRONMENTAL NGLTM-PERNITISERwCEa <br /> taD1 L HA2ELTON AVE.P.O.111 Pala STOCKTON,CAW, <br />